Required fields are marked with asterisks (*)

Medication Consent Form

If the participant requires medication (prescribed or over the counter) during the program time, please complete the following form.

Note: Please send the day's dosage only in the original container.

Name of participant

Your email address

Medication Information

Please enter the medication information. Select Add Medication to include up to five medications.

Name of medication

Dosage

Time Taken

Does the medication need to be taken with food, before meals or after meals?

Potential Reactions or side effects.

Refrigeration required.

Yes

Are there any other special instructions for this medication?

Yes

Is this a prescription medication?

Yes

Add Medication Remove

Consent Statement

I authorize the supervision only of dispensing the listed medication by the Municipality of Clarington Recreation staff, with the understanding that there is not a qualified medical person at the program and the above-named participant must administer his/her own medication. I agree to provide staff, on a daily basis, the daily prescribed dosage of medication only in the original prescribed container. With the following information; participant’s name, name and phone number of doctor, name of the medication, dosage and time to dispense the medication.